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The perioperative management of a parturient for cesarean delivery with a twin pregnancy complicated by abnormal placentation
Abstract Number: T-41
Abstract Type: Case Report/Case Series
Introduction: Abnormal placentation is a leading cause of obstetric hemorrhage and subsequent maternal morbidity and mortality. Currently there is no consensus on the peripartum anesthetic management of these patients for cesarean delivery. We report the management of a cesarean delivery for a parturient with a twin pregnancy complicated by placenta previa and placenta increta.
Case: The patient was a 35 year old G2P1 with a previous uncomplicated cesarean section at term who presented with a sentinel vaginal bleed at 29 weeks gestation. This pregnancy was significant for dichorionic diamniotic twins and complete placenta previa. Her BMI was 24 kg/m2. On admission she was hemodynamically stable with a hemoglobin of 12.7 g/dL and a fibrinogen of 574 mg/dL. Magnetic resonance imaging revealed a placenta increta and possible percreta of the anterior portion of the placenta and complete placenta previa with increta of the posterior portion of the placenta for twin B. She remained stable until a planned cesarean delivery was performed at 33 weeks gestation by a multidisciplinary team in a hybrid operating suite. A delayed hysterectomy was planned 2 weeks later. Pre-operative arterial line and central venous catheter access were established. In anticipation of large vertical midline abdominal incision, a T9-10 epidural catheter was placed in addition to a CSE performed at L3-4. The spinal component of the CSE was dosed with 12 mg of hyperbaric bupivacaine, 15 mcg of fentanyl, and 150 mcg of PF morphine, which provided a block to T6. Tranexamic acid 1 g was administered intravenously before delivery. Both twins were delivered uneventfully and both placentas were left in situ. Following uterine closure, bilateral uterine artery embolization was performed. The estimated blood loss was 750 mL and no blood products were transfused. In PACU, postoperative analgesia was initiated with PCEA 0.1% bupivacaine with 10 mcg/mL hydromorphone administered via the thoracic epidural. Approximately 5h later she developed cramping lower abdominal pain associated with profuse vaginal bleeding with 650 mL blood loss. She was taken back to the OR for an emergency total abdominal hysterectomy and salpingectomy performed under general anesthesia. There was evidence of hemorrhage at surgery from the placenta previa. She received another dose of tranexamic acid plus 4 units of packed RBC and 2 units of FFP were transfused. The estimated intraoperative blood loss was 1000 mL. Postoperatively the thoracic epidural was used for analgesia for 48h. She was discharged on postop day 5 without any further complications.
Discussion: The management of patients with abnormal placentation for cesarean delivery requires significant resources. Postoperatively, patients with the placenta left in situ need to be closely monitored for postoperative bleeding. Additionally the use of the thoracic epidural provides excellent postoperative analgesia for patients with midline incisions.